Healing the Mind through the Power of Story

The Promise of Narrative Psychiatry

Lewis Mehl-Madrona

• Publisher: Bear & Company
• Year: 2010
• ISBN:
  9781591439707
• Topic: Medicina
• Subtopic: Medicina alternativa e complementare

Psychiatry that recognizes the essential role of community in creating a new story of mental health • Provides a critique of conventional psychiatry and a look at what mental health care could be • Includes stories used in the author's healing practice that draw from traditional cultures around the world Conventional psychiatry is not working. The pharmaceutical industry promises it has cures for everything that ails us, yet a recent study on antidepressants showed there is no difference of success in prescribed pharmaceuticals from placebos when all FDA-reported trials are considered instead of just the trials published in journals. Up to 80 percent of patients with bipolar depression remain symptomatic despite conventional treatment, and 10 to 20 percent of these patients commit suicide. In Healing the Mind through the Power of Story, Dr. Mehl-Madrona shows what mental health care could be. He explains that within a narrative psychiatry model of mental illness, people are not defective, requiring drugs to "fix" them. What needs "fixing" is the ineffective stories they have internalized and succumbed to about how they should live in the world. Drawing on traditional stories from cultures around the world, Dr. Mehl-Madrona helps his patients re-story their lives. He shows how this innovative approach is actually more compatible with what we are learning about the biology of the brain and genetics than the conventional model of psychiatry. Drawing on wisdom both ancient and new, he demonstrates the power and success of narrative psychiatry to bring forth change and lasting transformation.

PART I

History and Foundations

1

Conventional Mental Health Today

Like play, art can reshape minds.

BRIAN BOYD, ON THE ORIGINS OF STORIES: EVOLUTION, COGNITION, AND FICTION

We accept all guests in the hospital emergency department, turning no one away, although administration has devised a new scheme for seeking deposits from patients who are classified as nonurgent, a status that our psychiatric patients have found clever ways to avoid. Considering their pain always urgent, these patients have learned magic words to defeat nonurgency. Whenever they arrive at emergency rooms they simply say, “I’m suicidal.”

Threats of suicide generate quick responses, especially in the context of nurses who are not particularly tolerant of psychiatric patients. They typically believe these people are taking up beds that could be used by others with “real diseases.”

The nurses dread the ugliness of the battles at the triage desk over deposit requests. “I’m afraid you’ll have to pay a deposit,” I once heard a nurse saying. “You don’t have an urgent condition because it’s been going on for the past six months.”

Other typical explanations given for requiring a financial deposit in our emergency department included:

“Because your doctor’s office is open and they say that they can see you.”

“Because you can go to the Health Department for your problem and they will treat you for free.”

“You could go to the VA Clinic today, and we’d be happy to call over and get you an appointment.”

“Would you be willing to see your own doctor, if we could get you an appointment there?”

But there are other ways to get classified as urgent besides suicide. Our psychiatric patients have also learned the value of chest pain: “That gets you seen right away, ’cause you might be having a heart attack,” whispered one of our frequent patients in the hallway, as he counseled a neophyte to tell the triage nurse about chest pain.

There are other tricks to being seen quickly, although psychiatric patients have a tendency to be rushed in and then left sitting for hours since no one knows what to do with them. Perhaps our hospital should have a special room with walls decorated with art done by our patients, paintings emerging from their madness. Desperation brought them to our demesne, and desperation should be depicted on our walls.

Coming Home

A howling prairie wind was blowing dust and flecks of snow against the sliding glass doors of the emergency department entrance. Psychiatric patients altered the mood of the emergency department in the way that an orchestra changes the feel of a concert hall when it starts to tune. Their presence was discordant and even cacophonous, yet there was a familiarity to them as if they represented a part of all of our families, or even of us.

I thought of them like the proverbial wolf of older times. Despite almost never attacking people, the wolf was reviled and avoided. For centuries people feared the gaze of a wolf as evil and sinister, believing that the stare of a wolf could make one speechless. In the Middle Ages, people steered their horses clear of wolf tracks, as it was believed that any horse whose hoof landed in a print would be crippled. Since that time, humans have shot wolves and displayed or buried them at the edges of their property and at town gates in hopes that the hides would keep other wolves away. No one ate wolf meat, as it was thought to be poisonous. This is how psychiatric patients are treated in emergency departments. Perhaps similar considerations apply to them as to the maligned wolf.

That evening I overheard the nurse explaining to “Jane,”^*1 a frail-appearing wisp of a woman who had visited us many times before, why she should leave the emergency department. “The Guidance Clinic will take care of this for you. You’ve been going there for as long as I’ve known you. They’re much better equipped to handle your questions and concerns than we are.”

“That’s nice,” Jane replied nervously. “Maybe I’ll just sit in the waiting room. Would you like that?”

Esther, the nurse, grew quiet and said, “I guess you could do that. I guess you could sit there as long as you want.” This was perhaps a desirable alternative to the way Jane usually visited us—in a diabetic coma or close to it. Jane regularly used her diabetes as a method of near suicide. When she felt depressed, she simply stopped taking her insulin. Rarely did she have to wait long. Her diabetes had become quite brittle, meaning that her glucose was all over the map, sometimes very low, sometimes very high, but unpredictably so. Jane hardly ever controlled her high blood glucose and was beginning to develop complications of the disease, including vision problems. The threat of becoming visually impaired made her even more miserable, which inevitably translated into another emergency room visit for ketoacidosis, the manifestation of out-of-control diabetes in which too much acid builds up in the blood and the person becomes unconscious.

Jane was often quietly weeping when the EMTs brought her to us on the stretcher, her glucose rarely less than seven hundred—seven times the normal value. She also could vomit on command and did so often. Lately, she had begun to dabble with heroin. One of our psychiatrists tried to have Jane committed to the state hospital because of her poor diabetes care. But a local judge threw the case out of court, even though Jane liked the state hospital.

“I’ll paint a picture for your waiting room,” Jane said. “I’ll paint you a picture of the gates of the state hospital.” She had been there enough times to memorize many facets of those run-down, rambling buildings in Las Vegas, New Mexico, that qualified as the state hospital. Jane told Esther that the bread was hard as rocks at the state hospital and you could burn yourself on the coffee when it first came out of the urns.

“But why do you want to wait here?” Esther asked, trying to explain that there wasn’t anything we could do for her, so it was pointless to wait for nothing.

I knew that Esther’s perception of what would help Jane was worlds apart from Jane’s, for we were Jane’s only family in a perverse sense of the word. We were among the few living beings on this earth who actually cared for her and ministered to her when she was sick. Jane’s coming to sit in the waiting room was actually a great improvement, although Esther could not see it that way. If only we could have exploited Jane’s search for more healthy contact with us by letting her stay in the waiting room or by giving her simple jobs to do around the emergency department, perhaps she might not have had to get sick in order to come see us.

When she replied, “Because this is home,” Jane was speaking so honestly that she sounded crazy. Jane had spent her childhood aching to be normal. Diabetes hit Jane hard in seventh grade and took a tyrannical hold over her. She had come to Clovis, New Mexico, in junior high school and, being already strange, had been excluded from the usual cliques and groupings of her peers—making her as isolated at school as she had been at home. Her whole life had become a bizarre mimicry of what she perceived normal to be. She could not lose the twang of Brooklyn, where she had lived until fate flung her across the country to the oil fields of New Mexico. Hard as she tried, her efforts at imitation caused her to be ridiculed.

Late evenings, when we were not terribly busy, I learned these things from Jane as I talked to her about her diabetes and her life, although as often as not, she refused to talk, catatonically suffering the nausea and abdominal pain of diabetic ketoacidosis until our drugs drowsily snowed her and calmed the turbulent waves of her stomach.

“Jane,” Esther almost scoffed, “we’re not your home.”

“Home is where the heart is,” Jane argued. “I’ll just stay here for a while, if you please. I’ll visit with my friend at the desk.”

Maybe the emergency department world was as off-kilter and bizarre as the atmosphere in her childhood home. Maybe it was the companionship Jane found with other patients in the waiting room that made her feel at home, as I have been told by other patients for whom the contact and humanity they found in the waiting room was more important than anything the doctor could tell them in the examining room. But there was something so deep and unsettlingly disturbed in Jane that she was excluded from much of the waiting room camaraderie. Occasionally someone befriended her, or more often than not, took advantage of her. Jane’s pain and sadness were like a killing dust that precipitated onto the furniture around her, as if from a cloud over her head, a dust that fellow patients fled to avoid and that caused staff to shun her as well.

Jane was afraid of dogs and cats and even her own shadow. She would sometimes peek at us from behind closed curtains when she was feeling better after one of her skirmishes with a coma. She jumped whenever anyone appeared to be coming near her. Her hands trembled when anyone interviewed her. She could not walk to the bathroom without looking behind her for hidden enemies creeping up to ambush her. I don’t know if she was even comfortable inside the bathroom with the door safely locked.

Jane told me her parents had grown darker, not older. She shared their trait of waking up screaming from nightmares in the middle of the night and sometimes in the middle of the emergency department. Once I had asked Jane what made her scream, and she told me I must have been dreaming, since she had not screamed. Another time she had screamed a man’s name over and over, although it was not a name we recognized, and afterward she denied screaming or having ever heard that name. This was typical of Jane’s response to our trying to comfort her. By denying doing what we wished to comfort, she made it difficult if not impossible for us to give her comfort. I wondered if she were truly dissociated from her experience, really not knowing it had happened, or if she was just afraid to share her inner processes with emergency department strangers.

Perhaps it was wise for her to refuse to share since we were not in a position to help her with that knowledge anyway. But the urge to share pain is strong; even strangers in bars discuss their marital problems, their hopes and dreams and aspirations, in ways that are decidedly intimate, perhaps because they will never see each other again. Often we are driven to share our pain with anyone who will listen, however inappropriate the setting, the context, or the person with whom we are sharing. Even so, we may speak in another language, one that hospital staff have no time or patience to learn. But this is what medicine must reclaim from indigenous traditions—stillness and a willingness to listen.

As Jane and Esther talked, I wondered how an indigenous healer would handle Jane. Perhaps the traditional healer would begin by following her, watching her movements carefully from the great oak tree outside her ramshackle, subsidized apartment, studying her as one might track game. Then, once he had really observed and understood her, he could offer healing.

In the years of my work in New Mexico, Jane’s darkness and unhappiness only deepened. She became fanatically absorbed with her music and carried her boom box with her all over town, only to have it stolen sometimes. This would precipitate another diabetic “underdose” and a visit to the emergency department, where Jane would continue her reticent patterns, with her baleful glares, her seeming hatred of and hostility toward those of us who took the time to care for her. The pain must have been acute, for our caring was ultimately mechanical and not lifesaving. Jane would sometimes sit up in bed and sing a plaintive, alley-cat cry, more off-key than the worse country singer, an expression of her diabetic delirium and her anguished life pain.

That night I talked to the nurses about Jane. I told them I would have liked to have worked with Jane were we to be in another context, another place, another time. I told them that someone should try to help her. But I could barely see the many patients that came and get my charting done. We did not have time to care. And the hospital’s corporate management was insisting that we see 20 percent more patients per day, even though we could barely handle the number of patients who were already coming through our entrance doors.

Esther’s response was to say, “No matter,” and to take command again by forcibly picking up the telephone and calling the Guidance Clinic. “Hello. One of your clients is sitting here at my triage desk. You better come get her right now. No, I don’t care if it’s not your job. She doesn’t belong in my emergency room. You’re responsible for her. You come get her right now. You’re supposed to be looking after these people or hadn’t you heard? I expect to see someone soon if you want to keep good relations here.”

Jane took a worn and ragged appointment card out of her purse and read it quietly before handing it to Esther, saying, “I guess I already have an appointment there. Maybe it all happened because of you.”

I looked up from my charting at the desk and saw Jane’s small, fearful face. She waved at me and I waved back. Life was a kind of concentration camp for Jane, her very own Bergen-Belsen, or at least I think this was what she was trying to tell us by refusing to control her diabetes. She could not leave the country of her hideous past. She played loud music through her boom box as some tawdry tribute to the pained spirits circling around her. Sometimes I thought I could see a lost soul peering out from Jane’s eyes. It was a look of tears and terror and uncontainable fury, so unlike the meek, downward gaze that Jane usually brokered.

Esther was trying to refuse to take credit for Jane’s appointment, which had existed before Jane pulled the card out of her purse. Jane insisted that the appointment and the card had not existed before Esther had just now thought to call the Guidance Clinic. People diagnosed with schizophrenia often speak the plain truth of quantum physics. They suffer because everyday life tends to ignore these insights and proceed as if quantum physics had never been invented. Physicists, shamans, and people diagnosed with schizophrenia all know that our reality is created as we go and that no evidence can be brought forth to explain a continuous world. A medicine person would agree with Jane that Esther had created that appointment card, like pulling a rabbit out of a hat. Each day our dreams and our nightmares are assembled, seemingly from nowhere, remaking the world from its raw material, bringing it into existence as we awaken, ceasing to exist when we close our eyes.

People diagnosed with schizophrenia and other sufferers with insight often reel under the shock of the truth and fall deeper and deeper into the abyss of their pain. You have to be smart to be crazy. Traditional healers, however, can bear these insights and still empty the garbage and cook dinner.

I prayed that Jane could meet a healer who could plumb the depths of her pain, the black gold lying beneath the surface of physics and mysticism, who could strike oil because he didn’t care to argue metaphysics; he already believed it and would dive straight for the pain. Healers see the tortured lives so many of us live hiding beneath our social pleasantries or, in Jane’s case, behind bizarre behavior. Maybe even a traveling evangelist could help. I have no doubt that some of them are genuine healers, their powers wrapped in a cocoon of Christianity, hidden to all but a discerning few. Jane’s spirituality bore fruit in darkness like a still-living moth whose silver, powdery wings are pinned as it is chloroformed and the lid of the collector’s case is closed.

Esther was finally giving up and telling Jane it was all right for her to go paint in the waiting room and wait for someone from the Guidance Clinic to come, although I was sure they were never going to come, having not been impressed by Esther’s pleas. Jane was telling Esther that they wouldn’t come, that nobody wanted her there—that was why she came to the emergency room. Jane was clearly communicating that she felt loved by us, that our physical gestures in placing her IV or exami...